Con Mi MADRE

Con Mi MADRE
Program Application
All information is kept in strict confidence. Please provide information for ALL sections of the application and print in ink.
Personal Information
Name: _________________________________________________________________ Date of Birth: ______________
Last First MI
Address: _________________________________________________________________________________________
Street Number & Name City State Zip Code
Home Phone: ______________________ Cell Phone: ______________________ Work Phone: _________________
Student Email: ____________________________________
____ Hispanic/Latino
Ethnicity: ____ Non-Hispanic/Latino
Free or Reduced Lunch: Yes ____ No ____
Parent Email: _________________________________
___ American Indian/Alaska Native
Race: ___ Asian
___ Black/African American
___ Native Hawaiian or Other Pacific Islander
___ White
School Information
Current Academic Year: 20___-___ Current Grade Level: _______ Current School: _________________________
Student ID #:_____________________
Middle School You Plan to Attend (Elementary Applicants Only): ________________________________ MS Grade Level:______
Indicate if you are participating in any of the following programs or school activities by placing a check mark on the
appropriate line.
Programs:
____ Migrant Education
____ Talent Search
____ AVID
____ GENaustin
____ GirlStart
Family Information
____ University Outreach
____ Breakthrough
____ College Forward
____ Girl Scouts
School Activities:
____ Student Council ____ School Clubs
____ Student Newspaper Club 1:
____ Student Yearbook Club 2:
____ Sports
Mother’s Name: ______________________________
Occupation: ________________________ Highest Grade Level: _________
Father’s Name: _______________________________ Occupation: ________________________ Highest Grade Level: __________
Does your father live at home (circle one)? Yes No Does your mother live at home (circle one)? Yes No
Number of immediate Number of family Number of family
family members: ______ living at home: ______ members in college: ______
Language(s) spoken at home: English_____ Spanish_____ Both_____
***Incomplete application or agreement will delay processing.***

Questions for Student Applicant
Do you consider attending college a top priority? (Check one) Yes
No
What are your educational goals?
_______________________________________________________________________________________
_______________________________________________________________________________________
How do you feel you would benefit from the Con Mi MADRE program?
_______________________________________________________________________________________
_______________________________________________________________________________________
Questions for Parent Applicant
Do you consider attending college a top priority for your daughter? (Check one) Yes
No
List your educational goals for your daughter.
_______________________________________________________________________________________
_______________________________________________________________________________________
How do you feel you and your daughter would benefit from the Con Mi MADRE program?
_______________________________________________________________________________________
_______________________________________________________________________________________
***Please call our office at 512-475-6309 with any questions about our program or the application process.***
** Incomplete application or agreement will delay processing **

PARTICIPATION AGREEMENT
Con Mi MADRE is designed to provide support and information to students and parents who participate in the program. These
services are intended to prepare students to enter a college or university upon graduation from high school.
Student and Parent:
I, ____________________________________ and ____________________________________ must meet the following conditions
Student
Parent(s) or Guardian
annually in exchange for the Con Mi MADRE services:
Middle School Program:
complete 10 hours of conference/workshop time
complete 15 hours of volunteer service in the community
maintain a grade point average of 2.5 (85) or better. Students not attending a school that holds regular campus
meeting must provide Con Mi MADRE a copy of their report card each six weeks.
Students attending targeted schools, barring tests or class projects, must attend all campus group meetings if in attendance
at school on meeting days
High School Program:
complete 10 hours of conference/workshop time
complete 20 hours of volunteer service in the community
maintain a grade point average of 2.5 (85) or better. Students not attending a school that holds regular campus meeting
must provide Con Mi MADRE a copy of their report card each six weeks.
Students attending targeted schools, barring tests or class projects, must attend all campus group meetings if in attendance
at school on meeting days
Attend one college visit per academic year. If applying for Con Mi MADRE scholarship, will need to attend 2 college
visits per academic year.
Note: If you do not meet these conditions by end of the school year, your membership in Con Mi MADRE will be terminated.
Students who attend or move to a non-targeted school can still participate in Con Mi MADRE.
Parent Approval of Student Participation
___________________________________________ is my child and is now under my control. She may participate in any
Student’s Name (please print)
and all Con Mi MADRE programs, trips, etc. for which she is eligible. In consideration of my child being permitted to make trips and
take part in Con Mi MADRE activities and the instruction my child will receive by reason thereof, I hereby relieve and release Con Mi
MADRE, its sponsoring and participating universities, colleges, school districts, organizations, and their respective officers,
employees, and agents, together with all those persons assisting with any phase of trips and all program activities (excluding paid
certified carriers) from any and all liability, responsibilities for making trips and activities and hereby releases all of said parties from
all liability by reason of any accident, injury or other harm that may be suffered by said child while on any trip or while participating
in any program activities. I agree to indemnify and hold all of said parties harmless from all claims hereafter made by or asserted on
behalf of the above named student.
______________________________________________________
Signature of Parent or Guardian
_______________________________________________
Printed Name
______________________________________________________
Date
** Incomplete application or agreement will delay processing **

Student Release and Sharing of Information Form
I, _______________________________________, parent of _______________________(Daughter’s Name) whose student
school identification number is ______________________________ gives Con Mi MADRE permission to obtain information
from her schools. My daughter has attended the following schools:
______________________________________________________ in ______________________________________
(School name)
(School District)
______________________________________________________ in ______________________________________
(School name)
(School District)
I understand that permission is being given so that:
Con Mi MADRE can obtain and/or provide the information below from the school, the Texas Education Agency, and partnering
agencies for evaluation purposes and in order to provide services that will help my child. These services may include but are not
limited to supportive guidance and counseling, mentoring, educational support, tutoring, and referral to other agencies.
Information Obtained:
Grades Disciplinary records Health Related Information
Attendance Records Free/Reduced lunch status
TAKS Class schedule
Other ___________________________________________________
Con Mi MADRE Information Sharing with Partnering Agencies
At times, Con Mi MADRE partners with community agencies that provide mental health services and college preparatory help
(i.e. College Forward). Con Mi MADRE needs permission to release information to referring agencies.
I, ____________________________________, parent of ____________________________________ [daughter’s name]
give permission to Con Mi MADRE to release information about my daughter to a partnering agencies, when applicable.
Information given will include:
Date of Birth Permanent Record Academic Record
Student Identification Phone Numbers
Free/Reduced Lunch Status
Rights of Consent: By signing this form, I acknowledge that I understand:
1. Records and information released under this consent will be kept confidential.
2. That this consent is voluntary and may be revoked at any time by informing Con Mi MADRE staff, in writing.
3. That I have the right to inspect and obtain a copy of any records released by this consent upon request in writing.
4. I understand that this consent is effective for the duration of enrollment in the program. I understand that release of
records under this consent is subject to any limitations placed by the federal and state law.
My signature below authorizes Con Mi MADRE to obtain information from schools my daughter has attended and to share
information with referring agencies.
Parent/Guardian Name (Please Print)_________________________________________________________________
Address:_____________________________________________City__________________Zip___________________
Telephone HM________________________WK_____________________Cell_______________________________
Parent/Guardian Signature____________________________________________ Date:_________________________
______________________________________________________________ Date: ________________________
Con Mi MADRE Staff Signature
** Incomplete application or agreement will delay processing **

Safety of Minors
All staff, volunteers, and interns associated with Con Mi MADRE are required by state law to report any abuse towards a minor. If
your daughter discloses information that indicates that she has been, or is currently being, abused as defined by state law, a report will
be made to the proper authorities including the Department of Family and Protective Services (formerly CPS) or Austin Police
Department. If your daughter discloses that she is in danger of harming herself or others, Con Mi MADRE will take the necessary
steps to ensure her safety, which may include contacting parents or community resources.
____________________________________________
Signature of Parent or Guardian
_________________________________________
Printed Name of Parent or Guardian
_________________________
Date
Non-Fee/Photo Release
I, ____________________________________________________ grant Con Mi MADRE permission to reprint my photograph and
my daughter’s photograph to be used for Con Mi MADRE publications, websites, electronic and digital media, publicity or
advertising. I understand that names may be used for picture captioning purposes when necessary. All photographs will remain the
property of Con Mi MADRE.
___________________________________________
Signature of Parent or Guardian
_______________________________________________
Printed Name of Parent or Guardian
________________________
Date
I DO NOT GIVE PERMISSION _____
** Incomplete application or agreement will delay processing **